Laserfiche WebLink
SA -63559 <br />Appendix 5 <br />Underground Storage Tank <br />Release Detection Equipment Testing Report Form <br />TESTING TYPE W Installation ❑ Repair ❑ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Test Date <br />k0 l"Y/5-0 ] _ __ _ �oaG-ol-o8 <br />Facility Name <br />Facility Address City ZIP Code <br />`leo W Ce n jC.- - M 41 e 953; <br />2. SERVICE TECHNICIAN INFORMATION <br />Manufacturer and Test Equipment Training Certifications <br />Company Performing Testing <br />Phone <br />et0-�27- 6$`x70 <br />X898) S69-8777 <br />_ <br />Mailing Addre <br />AC k qr6 <br />STP rfrming esting <br />ce T chniru'r, <br />H <br />Contractor License Number <br />7v.31q <br />ICC Certification <br />ICC Expiration Date <br />9WO <br />aW6-68-�o <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Training Expiration Date <br />et0-�27- 6$`x70 <br />14. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST 1 <br />1 hereby certify that all equipment identified in this form has been tested in accordance with <br />California Code of Regulations, title 23, division 3, chapter 16, section 2663; that required <br />supporting documentation is attached; and all information contained herein is accurate. <br />Se e Si ature Date Total # of Pages <br />1 1 :�hx_a 1 r0 R <br />CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br />ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, UDC = Under - <br />Dispenser Containment, UST = Underground Storage Tank, VPH = Vacuum/Pressure/Hydrostatic <br />Paget of 6 <br />